title: Family income in early childhood and subsequent attention deficit/hyperactivity disorder: a quasi-experimental study.
abstract: BACKGROUND
  Studies have found negative associations between socioeconomic position and attention deficit/hyperactivity disorder (ADHD), but it remains unclear if this association is causal. The aim of this study was to determine the extent to which the association between family income in early childhood and subsequent ADHD depends on measured and unmeasured selection factors.
  
  
  METHODS
  A total of 811,803 individuals born in Sweden between 1992 and 2000 were included in this nationwide population-based cohort study. Diagnosis of ADHD was assessed via the Swedish national Patient Register and the Swedish Prescribed Drug Register. Annual family income during offspring's first 5 years in life was collected prospectively from the Swedish Integrated Database for Labour Market Research and divided into quartiles by (lower) family disposable income. We predicted ADHD from family income while controlling for covariates and also comparing differently exposed cousins and siblings to control for unmeasured familial confounding.
  
  
  RESULTS
  The crude analyses suggested that children exposed to lower income levels were at increased risk for ADHD (HRQ uartile1  = 2.52; 95% CI, 2.42-2.63; HRQ uartile2  = 1.52; 95% CI, 1.45-1.58; HRQ uartile3  = 1.20; 95% CI, 1.14-1.15). This dose-dependent association decreased after adjustment for measured covariates (HRQ uartile1  = 2.09; 95% CI, 2.00-2.19; HRQ uartile2  = 1.36; 95% CI, 1.30-1.42; HRQ uartile3  = 1.13; 95% CI, 1.08-1.18). Although the association was attenuated in cousin comparisons (HRQ uartile1  = 1.61; 95% CI, 1.40-1.84; HRQ uartile2  = 1.28; 95% CI, 1.12-1.45; HRQ uartile3  = 1.14; 95% CI, 1.01-1.28) and sibling comparison models (HRQ uartile1  = 1.37; 95% CI, 1.07-1.75; HRQ uartile2  = 1.37; 95% CI, 1.12-1.68; HRQ uartile3  = 1.23; 95% CI, 1.04-1.45), it remained statistically significant across all levels of decreased disposable family income.
  
  
  CONCLUSIONS
  Our results indicated that low family income in early childhood was associated with increased likelihood of ADHD. The link remained even after controlling for unmeasured selection factors, highlighting family income in early childhood as a marker of causal factors for ADHD.
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Henrik
authors.initials: H
authors.lastname: Larsson
authors.forename: Amir
authors.initials: A
authors.lastname: Sariaslan
authors.forename: Niklas
authors.initials: N
authors.lastname: Långström
authors.forename: Brian
authors.initials: B
authors.lastname: D'Onofrio
authors.forename: Paul
authors.initials: P
authors.lastname: Lichtenstein
mesh_terms: D000328:Adult; D001289:Attention Deficit Disorder with Hyperactivity / Q000188:drug therapy / Q000191:economics / Q000209:etiology*; D005190:Family; D005260:Female; D006801:Humans; D007182:Income / Q000706:statistics & numerical data*; D010290:Parents; D010298:Parity; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult
keywords: ADHD; causality; childhood; family income; quasi-experimental approaches